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stroke or ischaemia-driven coronary revascularisation compared with the placebo group( 6.8 % vs 9.6 %; Hazard Ratio [ HR ]: 0.69; 95 % CI: 0.57-0.83; p < 0.001).
These positive results were echoed in the COLCOT trial. COLCOT randomised 4745 patients with a recent acute coro-
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Cardiovascular disease remains the leading cause of morbidity and mortality in Australia. |
particular AMI and stroke, as well as a lower risk of needing repeat revascularisation procedures. 2, 10
Safety
About 10-20 % of patients do not tolerate colchicine, which is similar to the rate of intol-
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established atherosclerotic cardiovascular disease that is poorly controlled despite optimal pharmacotherapy or with poorly controlled risk factors( see online resources). 13
Then later in 2023, the FDA approved its use in secondary prevention of CAD, and the AHA / ACC / ACCP / ASPC / NLA / PCNA
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evaluated by the CLEAR SYNERGY trial and the COLCARDIO-ACS trial, which is under recruitment. 15
Colchicine’ s role will also be expanded to the stroke literature, with the CASPER and CONVINCE trials assessing how colchicine’ s anti-inflammatory effects impact stroke
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nary syndrome( defined as being within 30 days post-MI) to low-dose colchicine 500 µ g daily or placebo. 9
At 22 months’ follow-up, colchi-
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erance associated with statins. The main reason is gastrointestinal upset, namely diarrhoea, which occurs early in the medication trial. This is often mild and transient. |
guidelines added a recommendation for use as secondary prevention in patients with CAD that is poorly controlled despite maximum tolerated guideline-directed medical |
16, 17 outcomes.
Conclusion
Cardiovascular disease remains the lead-
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cine-treated patients had a lower composite endpoint of death from cardiovascular causes, resuscitated cardiac |
This can usually be avoided by starting at a lower dose of 250 µ g daily before incrementing to the full dose of 500 µ g daily. |
therapy. 14 Despite this wide global uptake, the use of colchicine for secondary prevention is yet |
ing cause of morbidity and mortality in Australia, and further efforts must be made to improve patients’ residual coro- |
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arrest, MI, stroke, or urgent hospitalisation |
If this does not ameliorate the adverse |
to be integrated into Australian guidelines, |
nary risk. Colchicine has a firm evidence |
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for angina leading to coronary revascu- |
effect, the diarrhoea stops with cessation |
or TGA-approved for this indication. |
base in reduction of recurrence ischae- |
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larisation compared to the placebo group( 5.5 % vs 7.1 %; HR: 0.77; 95 % CI: 0.64-0.96; p = 0.02). 9 |
of colchicine. Otherwise, side effects seen with colchicine therapy occur at a similar rate to those observed with placebo. 11 |
Who should get colchicine?
Colchicine’ s main role is in the secondary
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mic coronary events in patients with stable CAD. It is also widely available, cheap and has a favourable safety profile. Given |
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The benefit of low-dose colchicine |
The other key clinical considerations are |
prevention of atherosclerotic cardiovascu- |
its efficacy and ease of access and use, this |
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was most significant in reducing the incidence of stroke and angina that required |
the use of colchicine in patients with chronic kidney disease stage IV or above( creatinine |
lar disease( ASCVD). The current evidence base demonstrates that colchicine shows |
under-utilised agent is an ideal adjunctive pharmacotherapy for patients with |
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revascularisation.
A recent meta-analysis pooled data from COLCOT, LoDoCo, LoDoCo2, COPS and a trial by Deftereos et al. This included 11,816 patients with established coronary disease, recent ACS and percutaneous coronary intervention( PCI) and demon-
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About 10-20 % of patients do not tolerate colchicine, which is similar to the rate associated with statins. |
promise in patients with established CAD and / or history of AMI. 7-10
The ideal patient for colchicine is one with demonstrated progression of CAD, either clinically with angina, or angiographically with further worsening stenoses, despite optimal medical therapy in the form of anti-
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established CAD.
References on request from kate. kelso @ adg. com. au
Online resources
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strated that colchicine reduced the risk of the primary endpoint of MACE( composite outcome of MI, stroke or cardiovascular death) by 25 %( Relative Risk [ RR ] 0.75; 95 % CI: 0.61-0.92; p = 0.005). 10
Specifically, colchicine reduced risk of MI by 22 %( RR 0.78; 95 % CI 0.64-0.94; p = 0.01), stroke by 46 %( RR 0.54; CI 0.34- 0.86; p = 0.009), and coronary revascularisation by 23 %( RR 0.77; 95 % CI 0.66-0.9; p = 0.005).
In summary, there is a firm bedrock of evidence that patients with CAD treated with colchicine have lower rates of subsequent ischaemic vascular events, in
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clearance of < 30mL / min), chronic liver disease
or in those with neutropenia. In regard to drug-drug interactions, colchicine should be discontinued when prescribing agents that are CYP3A4 inhibitors( ie, clarithromycin, ketoconazole, cyclosporin and ritonavir) as these increase the risk of colchicine toxicity. 12
Guidelines
Following the strength of the positive trials, colchicine use has been adopted into international guidelines. The 2021 ESC guidelines recommend colchicine for patients with
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platelet medications and lipid-lowering therapy. Of course, this needs to occur in concert with lifestyle modification in particular smoking cessation, healthy diet, regular exercise and contemporary lipid-lowering
2, 13, 14 therapy.
The specific patient population in those with established CAD who stand to benefit most is still under investigation.
Future directions
Management of inflammation is emerging
as an important treatment target for patients with vascular disease. Colchicine’ s benefit in the ACS population will be further
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• 2023 AHA / ACC / ACCP / ASPC / NLA / PCNA guidelines for the management of patients with chronic coronary disease bit. ly / 4cbdWjt
• 2021 ESC guidelines on cardiovascular disease prevention in clinical practice bit. ly / 4euxEZh
• Low-dose colchicine for secondary prevention of coronary artery disease: JACC review topic of the week bit. ly / 4b7YUKc
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